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times not all parties clearly understood the recommendations.
The researchers proposed
‘iSoBAR’ (where ‘I’ stands for Introductions,
‘O’ stands for Observations and replaces ‘A’ for
Assessment, which in turn becomes Agreed Plan,
and ‘R’ becomes Readback to confirm the agreed
plan of action). At the time of publication, this
variant was still in use in West Australia [91]. A
simpler variant, ISBAR (where ‘I’ stands for
‘Identify’) has been adopted by healthcare
authorities in other Australian States [92]; indeed
in Australia implementation of some version of
SBAR has been adopted as part of a national
standard of clinical handover [93]. However,
high-quality research on this widely used communication
tool, in whichever variant, is still
wanting [94].
30.6.4 Escalation of Concern: Graded
Assertiveness
In most clinical situations, where there is a clear
and agreed pathway for action and appropriate
leadership, safety is best maintained by cooperating
with the plan and deferring to one’s superiors.
However plans do not always proceed as
expected; if errors or mishaps occur, or an imminent
threat to safety arises, it is sometimes necessary
for healthcare providers to assert
themselves in a clear and timely fashion to support
patient safety [67]. As there are many hierarchical
structures in healthcare with many
authority gradients between individuals, speaking
up to senior colleagues does not come naturally
to many people, especially junior personnel,
even in the face of an overt safety issue.
Organisations that employ clinicians with a duty
of care to patients must therefore seek to
empower staff by providing them with training
in assertion techniques.
An example of assertive language is the twochallenge
rule, where a concern is stated at least
two times to better ensure it has been heard. The
CUS tool (Concerned, Uncomfortable, Safety
issue) also part of the TeamSTEPPS framework
escalates communication from an expression of
S. Prineas et al.
concern through a command to stop. The escalation
of concern consists of, ‘I’m concerned’, ‘I’m
uncomfortable’, ‘this is unsafe’, meaning ‘This is
a potential serious problem. Stop and listen to
me’. [148]. Frankel and Leonard [95] suggest
that the true ‘test’ of teams and leaders occurs
when the ‘line is stopped’ after someone raises a
concern, which then turns out to have been a false
alarm.
Another tool, derived from the aviation-based
PACE algorithm [96], is Graded Assertiveness.
The tool comprises four levels of assertion—
Observation, Suggestion, Challenge and
Emergency—and has been adapted for use in
clinical environments [69]. An example of the
tool is given in Fig. 30.3.
30.7 Teamwork and Leadership
Skills
A team can be defined as ‘a distinguishable set of
two or more individuals who interact dynamically,
adaptively, and interdependently; who
share common goals or purposes; and who have
specific roles or functions to perform’ [97].
Successful teams are the product of time, effort
and trust. As teams are also defined as social entities
[98] that at times perform highly technical
functions, there may be value in regarding healthcare
teams as microcosms of a wider sociotechnical
system, particularly in regard to improving
patient safety [99].
Be it in a community health service or a large
hospital, teams come in many forms: teams
overlapping with other teams, teams nested
within teams, teams dispersed in time and geographical
space. It is therefore not surprising
that there is a large variation among doctors in
their conceptualisations of what and where
teams are [100]. It may not be obvious to an
individual practitioner where the team is, or
even if one exists, for the task they are trying to
perform. Moreover, there is a growing (albeit
belated) recognition that patients and their families
should be considered as part of the healthcare
team [101].